Richmond AQP Neck & Back Pain Referral Form

PATIENT DETAILS / PRACTICE DETAILS
Name / Date of Referral
DoB / Referring GP
Address / Practice Address
Telephone: Home / Telephone
Telephone: Mobile / Fax
Consent to leave message / Yes No / E-mail
NHS Number
Gender / Interpreter Required / Yes No
Ethnicity / Language
Please complete the following details fully to avoid delays in treatment:
Diagnosis
Duration / <6 weeks / 6-12 weeks / Other:
Previous treatments
Is the patient off work due to the problem? / Yes No
Investigations / (please attach scan reports)
If Red Flag symptoms are present, please consider secondary referral:
Urgent Symptoms / Red Flags
Severe/poorly controlled pain / Age <18 or >55 / Malaise
Severe sleep disturbance / History of cancer / Steroid use
Condition likely to deteriorate quickly without action / Non-mechanical pain / Immunosuppression
Severe impairment of activities of daily living / Thoracic pain / Trauma
Deteriorating neurological states / Unexplained weight loss / Symptoms of Cauda equina
Relevant Medical History
Current medication
Other relevant information
STarT Back Score / /9 / Sub-Score / /5

Please note: STarT Back score MUST be entered or referral will not be accepted (See StarT Back scoring sheet).
Please ensure StarT Back Score completed for all referrals

Disagree / Agree
0 / 1
1 / My back pain has spread down my leg(s) at some time in the last 2 weeks
2 / I have had pain in the shoulder or neck at some time in the last 2 weeks
3 / I have only walked short distances because of my back pain
4 / In the last 2 weeks, I have dressed more slowly than usual because of back pain
5 / It’s not really safe for a person with a condition like mine to be physically active
6 / Worrying thoughts have been going through my mind a lot of the time
7 / I feel that my back pain is terrible and it’s never going to get any better
8 / In general I have not enjoyed all the things I used to enjoy

9. Overall, how bothersome has your back pain been in the last 2 weeks?

Not at all / Slightly / Moderately / Very much / Extremely
0 / 0 / 0 / 1 / 1

Total score (all 9): Sub Score (Q5-9):

The STarT Back Tool Scoring System

Use STarT back score and sub score to stratify risk and aid management approach:

For low risk patients, please consider alternative treatments prior to referral